Dear Editor,
Controlling hospital costs is a key priority for health system managers. In this regard, inappropriate hospital admissions significantly drive up costs and impair system efficiency and effectiveness (1-3). This issue imposes an unnecessary financial burden on both the health system and patients, occupies beds reserved for genuine patients, and increases the workload of healthcare personnel, ultimately lowering service quality. Key contributing factors include changes in hospitalization policies, lack of precise mechanisms to assess admission necessity, and deficiencies in the referral system and service stratification (3-6). Furthermore, the implementation of Iran’s Health Transformation Plan (HTP), intended to increase access to hospital services and reduce costs, has paradoxically been associated with increased workload and hospitalizations, which may partly explain the rise in inappropriate admissions (7, 8).
Local Study in Southeast of Iran and National Perspective Development
In a cross-sectional study conducted in 2020 in the two largest public hospitals affiliated with Zahedan University of Medical Sciences (ZAUMS), 8.3% of admissions and 3.5% of hospital days were rated inappropriate. Additionally, 12% of laboratory services, physician visits, nursing care, and pharmaceutical interventions were deemed unnecessary. The highest rates were found in internal medicine and surgical departments in public hospitals (3). A national systematic review and meta-analysis of 17 studies reported a pooled inappropriate admission rate of 12.3% (95% CI: 8.4% - 17.5%) and a hospitalization rate of 11.9% (95% CI: 7.7% - 18.1%). Notably, the admission rate declined after the HTP from 14.6% to 10%, while the hospitalization rate increased post-plan from 9.5% to 16.9% (9). In Semnan (2014), inappropriate admissions were 7.4% and inappropriate hospital stays were 22.1%, mostly attributed to delays in diagnostics and conservative physician discharge policies (10). A study in Shiraz (2010) estimated an inactive admission rate of 22% and inappropriate stays around 29.6%, with a clear link between inappropriateness, longer length of stay, and increased cost (11). At Tehran University hospitals, about 8.6% of hospital days were considered inappropriate, often tied to specialty-specific and administrative factors (12).
These findings confirm that inappropriate hospital utilization is a widespread issue across Iran and support the need for nationally scalable solutions.
Policy Making and Practical Suggestions
Based on local and national evidence, we recommend the following policy interventions, presented conceptually under thematic headings to enhance clarity and applicability.
1. Referral system and clinical guidelines: (A) optimizing the referral system by strengthening primary and outpatient care to reduce unnecessary admissions; (B) developing and implement standard clinical guidelines for admission and discharge, substantiated by protocols such as the appropriateness evaluation protocol (AEP), which have demonstrated utility in credible studies (11, 12).
2. Triage processes and artificial demand control: (A) reforming clinical triage mechanisms and hospital entry points, particularly in the emergency department and for surgery scheduling; (B) controling induced demand for elective patients through follow-up, monitoring, and documentation of admission reasons.
3. Human resources and specialist oversight: (A) increasing the presence of internists, senior surgeons, and hospitalists in public hospitals to expedite decision-making and reduce unnecessary lengths of stay; (B) actively monitoring physician activities — studies have shown that physician-related factors account for the largest share of inappropriate admissions (9).
4. Training, monitoring, and digital infrastructure: (A) providing continuous training and awareness to healthcare staff regarding the importance of appropriate admissions and assessment methods; (B) establishing an electronic monitoring system within patient records to log and flag inappropriate admissions and unjustified stays.
5. Timely discharge and bed capacity management: Expediting the discharge of patients who no longer require hospitalization and prevent the cancellation of scheduled surgeries to improve bed productivity (3).
Conclusions
In summary, the combination of findings from ZAUMS and national studies reveals that rates of inappropriate admissions and stays in Iran range from 7% to over 22%, depending on region and timeframe. This demonstrates an urgent need for systematic policy reform. Our focused recommendations, particularly on strengthening referral systems, clinical guidelines, and specialist oversight, are both context-sensitive and adaptable to diverse healthcare settings. Such reforms are expected to reduce hospital expenditures, enhance health system efficiency, and ultimately improve the quality of healthcare services.
